.

1. Staging and investigations of CA
hepatobilliary system and pancreas
Dr Atul Gupta
Junior Resident
Deptt of Radiation oncology
AIIMS JODHPUR

2. Learning Objectives-
1. Liver cancer Epidemiology
2. Risk factors for liver CA development
3.Clinical features of liver CA
4.Gall Baldder CA epidemiology
5.Gall baldder ca risk factors
6. Gall bladder CA presentation
7. CA pancreas epidemiology,risk factors and presentation
8.Diagnosis of CA liver,GB,Pancreas
9.Staging of CA liver,GB and pancreas

3. Liver cancer Epidemiology -
The annual number of worldwide liver cancer cases (748,300) closely resembles
the number of deaths (695,900). Long-term survival rates are 3% to 5% in most
cancer registries. In 2016, 39,230 new cases of liver and intrahepatic bile duct
cancers were diagnosed in the United States, responsible for 27,170
deaths.Globally, HCC is 2.3 times more common in men than in women, and
likely due to androgen receptors (ARs) on some of these tumors.There has been
a significant overall increase in the incidence of HCC in the United States during
the past 25 years.This parallels the increase in HCV infection, the increase in
immigrants from HBV-endemic countries, and an increase in nonalcoholic fatty
liver disease (NAFLD). The widespread utilization of HBV vaccination is leading
to a decrease in liver cancer. In Taiwan, introduction of HBV vaccination in 1984
led to a reduction of liver cancer from 0.54 per 100,000 to 0.2 per 100,000 over a
16-year period.

4. Risk Factors for CA Liver-

5. Clinical presentation of liver Cancer -
1. Asymptomatic - 24%
2. Abdominal pain - 40%
3. Other ( work up of anaemia and various disease) - 12%
4. Routine physical examination and elevated LFT- 24%
5. Weight loss- 20%
6. Appetite loss- 11%
7. Weakness / malaise- 15%
8. Jaundice- 5%
9. Cirrhosis features- 18%
10. Diarrhoea , tumor rupture- 1%

9. Diagnosis Of Liver Cancer-
Test used to diagnose HCC include radiologic studies and pathologic diagnosis with biopsy. Core biopsies are most preferred
because of the tissue architecture given by this technique. For patients suspected of having portal vein involvement, a core biopsy of
the portal vein may be performed. Morphologic features, such as stromal invasion, help distinguish high-grade dysplastic nodules
from HCC.
The American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL)
have outlined noninvasive criteria for the diagnosis of HCC.
EASL recommends that lesions that are >2 cm with characteristic radiologic features of arterial hyperenhancement on two different
imaging modalities, or on one imaging modality alongside with a serum α-fetoprotein (AFP) of 400 ng/dL or more, are diagnostic of
HCC, and no biopsy is needed.
The AASLD added venous washout as a requisite radiologic feature. Detection of a lesion >2 cm that exhibits both arterial
hyperenhancement and venous washout in a single imaging modality concomitant with an AFP >200 ng/mL is sufficient to diagnose
HCC. Bialecki et al. found a sensitivity and specificity of 89.1% and 100%, respectively, for liver biopsy compared to 64.9% and 62.8%,
respectively, for the noninvasive EASL criteria. There is fear of biopsy-related hemorrhage and tumor seeding associated with
biopsies. However, data show that hemorrhage occurs at only a 0.4% rate, and tumor seeding occurs at a low rate of 1.6%. When
seeding does occur, it can be treated by local resection and is seldom a cause of morbidity and mortality.

12. Gall Bladder Cancer
EPIDEMIOLOGY
Gallbladder cancer is the most common biliary tract cancer. The vast majority of
gallbladder cancers are adenocarcinomas. Incidence steadily increases with age,
women are more likely to be diagnosed with gallbladder cancer than men, and
incidence and mortality rates in the United States are highest among American
Indian and Alaska Native men and women. However, the incidence of gallbladder
cancer has decreased in women but went up in the black population and those
younger than 45 years of age. Globally, there are pockets of increased incidence in
Korea, Japan, some areas of Eastern Europe and South America, especially Chile,
Spain, and in women in India, Pakistan, and Ecuador. Gallbladder cancer is
characterized by local and vascular invasion, extensive regional lymph node
metastasis, and distant metastases. Gallbladder cancer is also associated with
shorter median survival duration, and shorter survival duration after recurrence than
hilar cholangiocarcinoma

13. Risk Factors-
1. Inflammatory
A. Gall stones
B.porcelain GB
C. Primary sclerosing cholangitis
D. Anamolous pancreaticobilliary duct junction
E. Chronic infection
2. Non inflammatory
A. Gender (F>M)
B. Age
C. Socioeconomic status
D. Genetics
E. Aflatoxins

14. Clinical Features-
1. Pt with GBC are often asymptomatic. When symptoms occur, they may be similar to
biliary colic or chronic cholecystitis and are nonspeciifc. In contrast to biliary colic, patients
with GBCs may have diffuse abdominal pain of a more constant nature. As a result of the
low index of suspicion, patients with GBC present with symptoms at an advanced stage of
disease or as incidental findings at the time of imaging or cholecystectomy for unrelated
reasons. Recent weight loss and persistent right upper quadrant pain should raise the
suspicion of GBCs in elderly patients older than 70 years of age.
2. Jaundice can result from the obstruction of extrahepatic bile ducts by direct tumor growth
or from metastatic disease. Jaundice is a poor prognostic sign, and 85% of patients with
jaundice have unresectable tumors.
3. Mirizzi syndrome, in which compression of the common hepatic duct results from an
impacted stone in the gallbladder neck, can be a presentation of GBC.
4. Rarely, duodenal or colonic obstruction; cholecystoenteric fistula; or evidence of extra-
abdominal metastases such as palpable mass, ascites, or paraneoplastic syndromes such
as acanthosis nigricans may occur. These indicate an advanced malignancy and
unresectable disease

15. Diagnosis -
1. Blood investigation-
A. CBC
B. KFT
C. LFT panel
D. Tumor markers- a. S.CEA- value >4ng/ml is 93% specific in CA
GB but 50% sensitive
b. S. CA19-9 value above 20U/ml is 79%sensitive as well as
specific for CA GB
c. S. CA125

16. 2. Radiological Investigation -
1. Ultrasound-
US of the gallbladder can show findings that that are suggestive, but not
diagnostic, of GBCs include thickening of the wall, a lumenal mass, a
calcification, or a mass lesion. A polypoid mass was present in 27% and a
gallbladder-replacing or invasive mass was present in 50% of cases of GBC
examined. Mucosal thickening should be viewed with suspicion.
2. CT Abdomen -
Abdominal CT scans or MRI can identify intraluminal polyps, gallbladder
wall thickening, mass lesions, hepatic involvement, nodal enlargement, or
other distant spread. CT scanning will reveal a mass partially obliterating
the gallbladder lumen, a polypoidal mass, or diffuse wall thickening.
However, only one-third of pathologically positive nodes are identified
preoperatively by CT scan.

17. 3. MRCP
MRCP may provide more detailed information than can be provided by US
or CT scan
4.MRI
MRI may be helpful in determining vascular invasion and nodal involvement.
5. PET-Scan
Fluorodeoxyglucose-PET scanning has low sensitivity for
extrahepatic disease. However, PET scanning may identify
disease and resulted in a change in stage and treatment in 17% to
23% of cases with presumed localized resectable disease in one
study.

18. 6. Pathological investigation-
The need for tissue biopsy before definitive exploration and resection of a mass that is suspicious for
GBC is controversial because of the risks of the tumor seeding into the peritoneal cavity or abdominal
wound.
A. Bile cytology may avoid these and should be performed whenever any patient suspected of having
GBC undergoes ERCP or PTC. The diagnostic accuracy of combined ERCP and bile cytology is 50%
for GBCs. The sensitivity of bile cytology alone for the diagnosis of GBC has been reported between
50% and 73%.131 If referral for surgical management is being considered, a diagnosis based on bile
cytology or percutaneous FNA cytology would be preferable to operative or laparoscopic biopsy.
B. Percutaneous FNA or core needle biopsy are indicated for unresectable masses. The risk of tumor
seeding within the needle tract is greater with the latter.
C. EUS-directed FNA for gallbladder lesions is associated with a80% sensitivity and 100% specificity.

20. Cholangiocarcinoma
Cholangiocarcinomas encompass all tumors originating in the
epithelium of the bile duct. More than 90% of cholangiocarcinomas
are adenocarcinomas .
Cholangiocarcinomas are diagnosed throughout the biliary tree and
are typically classified as either intrahepatic or extrahepatic
cholangiocarcinoma. Extrahepatic cholangiocarcinomas are more
common than intrahepatic cholangiocarcinomas

21. Intrahepatic Cholangiocarcinoma

23. Extrahepatic Cholangiocarcinoma

25. Ca Pancreas
Epidemiology-
Pancreatic ductal adenocarcinoma (PDA) is the 12th most common
cancer in the United States, with 54,000 new cases each year in the
United States. The lifetime risk is 1.5%, and the median age at
diagnosis is 70 years. The disease is principally one of aging
because almost 90% of cases occur after the age of 55 years

26. Risk Factors for Ca pancreas
1. Non Genetic Risk Factors-
A. Tobacco
B. H pylori infection
C. Non O blood group
D. Heavy alcohol intake
E. Obesity
F. Diabetes mellitus
G. Low fruit intake
F. Red meat intake

27. Genetic Risk Factors-

28. Clinical Features-
Early symptoms of pancreatic cancer result from a mass effect.
Approximately 60%–70% of pancreatic cancer arises in the head of the
pancreas, 20%–25% in the body and the tail, and the remaining 10%–
20% diffusely involve the pancreas.
A. Tumours located in the body and the tail are likely to be diagnosed at a
more advanced stage than tumours located in the head, as these can
develop symptoms related to an obstruction of the common bile duct
and/or the pancreatic duct.
B. Common presenting symptoms of pancreatic cancers include jaundice
(for tumours of the head), abdominal pain, weight loss, steatorrhoea, and
new-onset diabetes.
C.Tumours can grow locally into the duodenum (proximal for tumour of
the head and distal for tumour of the body and tail) and result in an upper
gastroduodenal obstruction.

29. Diagnosis-
1. Lab investigations
A. CBC
B. LFT panel
C. KFT
D. Hepatitis panel
E. Baseline tumor marker- CA 19-9 and CEA

30. 2. Radiological investigations
A. CECT Abdomen and pelvis-
preferred due to better resolution and detailed depiction of vasculature

31. B. CEMRI-
MRI is most commonly used as a problem-solving tool, particularly for
characterization of CT-indeterminate liver lesions and when suspected
pancreatic tumors are not visible on CT or when contrast-enhanced CT cannot
be obtained (as in cases with severe allergy to iodinated intravenous material)
C. PET SCAN-
Positron emission tomography (PET)/CT does not add much additional value
and is not routinely performed in the initial assessment for resectability.

32. 3. Pathological Diagnosis
1. EUS-FNA/fine-needle biopsy (FNB) is preferable to a CT-guided FNA in patients
with resectable disease because of better diagnostic yield, safety, and potentially
lower risk of peritoneal seeding with EUS-FNA/FNB when compared with the
percutaneous approach. Biopsy proof of malignancy is not required before surgical
resection, and a non-diagnostic biopsy should not delay surgical resection when the
clinical suspicion for pancreatic cancer is high.
2. Diagnostic staging laparoscopy to rule out metastases not detected on imaging
(especially for body and tail lesions) is used in some institutions prior to surgery or
chemoradiation, or selectively in patients who are at higher riskb for disseminated
disease. Intraoperative ultrasound can be used as a diagnostic adjunct during
staging laparoscopy.
3. Positive cytology from washings obtained at laparoscopy or laparotomy is
equivalent to M1 disease. If resection has been done for such a patient, he or she
should be treated for M1 disease.

34. Thanks